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On W, Saleem MA, Hegade VS, Huggett MT, Paranandi B, Everett SM. Factors predicting 30-day mortality after ERCP in patients with inoperable malignant hilar biliary obstruction: a single tertiary referral centre experience and systematic review. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000878. [PMID: 35301232 PMCID: PMC8932256 DOI: 10.1136/bmjgast-2022-000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/21/2022] [Indexed: 12/07/2022] Open
Abstract
Objective There is a paucity of studies in the literature body evaluating short term outcomes following endoscopic retrograde cholangiopancreatography (ERCP) in patients with inoperable malignant hilar biliary obstruction (MHBO). We aimed to primarily evaluate 30-day mortality in these patients and secondarily, conduct a systematic review of studies reporting 30-day mortality. Design We conducted a retrospective analysis of all patients with inoperable MHBO who underwent ERCP at Leeds Teaching Hospitals NHS Trust between February 2015 and September 2020. Logistic regression models constructed from baseline patient data, the modified Glasgow Prognostic Score (mGPS) and Charlson Comorbidity Index (CCI) were evaluated as predictors of 30-day mortality. Results Eighty-seven patients (49 males) with a mean age of 70.4 years (SD ±12.3) were included. Cholangiocarcinoma was the most common aetiology of MHBO affecting 35/87 (40.2%). Technical success was achieved in 72/87 (82.8%). The 30-day mortality rate was 25.3% (22/87), of which 16 were due to progression of underlying malignant disease. On multivariate analysis, only leucocytosis (OR 4.12, 95% CI 2.70 to 7.41, p=0.02) was an independent predictor of 30-day mortality. Neither mGPS (p=0.47) nor CCI with a cut-off value of ≥7 (p=0.06) were significant predictors of 30-day mortality. Conclusion We demonstrated that 30-day mortality following ERCP for inoperable MHBO remains high despite technical success. Further studies are warranted to identify patients most appropriate for intervention.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Muhammad A Saleem
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vinod S Hegade
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon M Everett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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2
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Boškoski I, Schepis T, Tringali A, Familiari P, Bove V, Attili F, Landi R, Perri V, Costamagna G. Personalized Endoscopy in Complex Malignant Hilar Biliary Strictures. J Pers Med 2021; 11:jpm11020078. [PMID: 33572913 PMCID: PMC7911877 DOI: 10.3390/jpm11020078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/13/2022] Open
Abstract
Malignant hilar biliary obstruction (HBO) represents a complex clinical condition in terms of diagnosis, surgical and medical treatment, endoscopic approach, and palliation. The main etiology of malignant HBO is hilar cholangiocarcinoma that is considered an aggressive biliary tract's cancer and has still today a poor prognosis. Endoscopy plays a crucial role in malignant HBO from the diagnosis to the palliation. This technique allows the collection of cytological or histological samples, direct visualization of the suspect malignant tissue, and an echoendoscopic evaluation of the primary tumor and its locoregional staging. Because obstructive jaundice is the most common clinical presentation of malignant HBO, endoscopic biliary drainage, when indicated, is the preferred treatment over the percutaneous approach. Several endoscopic techniques are today available for both the diagnosis and the treatment of biliary obstruction. The choice among them can differ for each clinical scenario. In fact, a personalized endoscopic approach is mandatory in order to perform the proper procedure in the singular patient.
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Affiliation(s)
- Ivo Boškoski
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | - Tommaso Schepis
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Andrea Tringali
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Pietro Familiari
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Vincenzo Bove
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Fabia Attili
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Rosario Landi
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Vincenzo Perri
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
| | - Guido Costamagna
- Center for Endoscopic Research Therapeutics and training (CERTT), Università Cattolica del Sacro Cuore, 20123 Rome, Italy; (T.S.); (A.T.); (P.F.); (V.B.); (F.A.); (R.L.); (V.P.); (G.C.)
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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3
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Aghaie Meybodi M, Shakoor D, Nanavati J, Ichkhanian Y, Vosoughi K, Brewer Gutierrez OI, Kalloo AN, Singh V, Kumbhari V, Ngamruengphong S, Khashab MA. Unilateral versus bilateral endoscopic stenting in patients with unresectable malignant hilar obstruction: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E281-E290. [PMID: 32118102 PMCID: PMC7035140 DOI: 10.1055/a-1067-4326] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/16/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Endoscopic stent placement is used for palliative management of unresectable malignant hilar obstruction, which could be achieved by either unilateral or bilateral stent insertion. Materials and methods A literature search was performed to identify studies that reported outcomes of metallic biliary stent placement in patients with malignant hilar obstruction. Weighted pooled rates (WPR) along with 95 % confidence intervals (95 %CI) were calculated to determine and compare outcomes including technical and functional success, early and late adverse events, post procedure cholangitis, and stent occlusion between two groups. Results A total of 21 studies with 1292 patients were included. WPR of technical success was significantly higher in the unilateral group (97 %, 95 %CI: 93 -98 %) vs. bilateral group (89 %, 95 %CI: 84 -92 %) ( P = 0.0.003). WPR for functional success in the unilateral and bilateral groups were 96 % (95 %CI: 91 -98 %) and 94 % (95 %CI: 91 -97 %), respectively ( P = 0.48). The rate of early and late complications was comparable between the two groups. Conclusion In patients with unresectable malignant hilar obstruction, unilateral and bilateral metallic stenting techniques are comparable in terms of efficacy and safety.
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Affiliation(s)
- Mohamad Aghaie Meybodi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Delaram Shakoor
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland, United States
| | - Julie Nanavati
- Welch Medical Library, Johns Hopkins University, Baltimore, Maryland, United States
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Kia Vosoughi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Olaya I. Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Anthony N. Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Vikesh Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States,Corresponding author Mouen Khashab MD, Associate Professor of Medicine, Director of Therapeutic Endoscopy Division of Gastroenterology and HepatologyJohns Hopkins Medical Institutions1800 Orleans StSheikh Zayad 7E Rm 7125GBaltimore, MD 21224+1-443-287-1960
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4
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Lee JM, Lee SH, Jang DK, Chung KH, Park JM, Paik WH, Lee JK, Ryu JK, Kim YT. Air cholangiography in endoscopic bilateral stent-in-stent placement of metallic stents for malignant hilar biliary obstruction. Therap Adv Gastroenterol 2016; 9:189-98. [PMID: 26929781 PMCID: PMC4749855 DOI: 10.1177/1756283x15618132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Although endoscopic bilateral stent-in-stent (SIS) placement of self-expandable metallic stents (SEMS) is one of the major palliative treatments for unresectable malignant hilar biliary obstruction, post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis can occur frequently due to inadequate drainage, especially after contrast injection into the biliary tree. The aim of this study is to evaluate the efficacy and safety of air cholangiography-assisted stenting. METHODS This study included 47 patients with malignant hilar biliary obstruction who underwent endoscopic bilateral SEMS placement using the SIS technique. They were divided into two groups, air (n = 23) or iodine contrast (n = 24) cholangiography. We retrospectively compared comprehensive clinical and laboratory data of both groups. RESULTS There were no significant differences found between the two groups with respect to technical success (87% versus 87.5%, air versus contrast group, respectively), functional success (95% versus 95.2%), 30-day mortality (8.3% versus 8.7%) and stent patency. Post-ERCP adverse events occurred in 5 (21.7%) of the patients in the air group and 8 (33.3%) of the patients in the contrast group. Among these, the rate of cholangitis was significantly lower in the air group (4.8% versus 29.2%, p = 0.048). In multivariate analysis, air cholangiography, technical success and a shorter procedure time were significantly associated with a lower incidence of post-ERCP cholangitis. CONCLUSIONS Air cholangiography-assisted stenting can be a safe and effective method for endoscopic bilateral SIS placement of SEMS in patients with malignant hilar biliary obstruction.
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Affiliation(s)
- Jae Min Lee
- Departments of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea,Department of Internal Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | | | - Dong Kee Jang
- Departments of Internal Medicine and Liver Research Institute, Seoul, Korea,National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kwang Hyun Chung
- Departments of Internal Medicine and Liver Research Institute, Seoul, Korea,National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Myung Park
- Department of Internal Medicine, Kangwon National University School of Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Ji Kon Ryu
- Departments of Internal Medicine and Liver Research Institute, Seoul, Korea,National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yong-Tae Kim
- Departments of Internal Medicine and Liver Research Institute, Seoul, Korea,National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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Singh RR, Singh V. Endoscopic management of hilar biliary strictures. World J Gastrointest Endosc 2015; 7:806-13. [PMID: 26191345 PMCID: PMC4501971 DOI: 10.4253/wjge.v7.i8.806] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 03/26/2015] [Accepted: 04/10/2015] [Indexed: 02/05/2023] Open
Abstract
Hilar biliary strictures are caused by various benign and malignant conditions. It is difficult to differentiate benign and malignant strictures. Postcholecystectomy benign biliary strictures are frequently encountered. Endoscopic management of these strictures is challenging. An endoscopic method has been advocated that involves placement of increasing number of stents at regular intervals to resolve the stricture. Malignant hilar strictures are mostly unresectable at the time of diagnosis and only palliation is possible.Endoscopic palliation is preferred over surgery or radiological intervention. Magnetic resonance cholangiopancreaticography is quite important in the management of these strictures. Metal stents are superior to plastic stents. The opinion is divided over the issue of unilateral or bilateral stenting.Minimal contrast or no contrast technique has been advocated during endoscopic retrograde cholangiopancreatography of these patients. The role of intraluminal brachytherapy, intraductal ablation devices, photodynamic therapy, and endoscopic ultrasound still remains to be defined.
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6
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Goenka MK, Goenka U. Palliation: Hilar cholangiocarcinoma. World J Hepatol 2014; 6:559-569. [PMID: 25232449 PMCID: PMC4163739 DOI: 10.4254/wjh.v6.i8.559] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/07/2014] [Accepted: 06/16/2014] [Indexed: 02/06/2023] Open
Abstract
Hilar cholangiocarcinomas are common tumors of the bile duct that are often unresectable at presentation. Palliation, therefore, remains the goal in the majority of these patients. Palliative treatment is particularly indicated in the presence of cholangitis and pruritus but is often also offered for high-grade jaundice and abdominal pain. Endoscopic drainage by placing stents at endoscopic retrograde cholangio-pancreatography (ERCP) is usually the preferred modality of palliation. However, for advanced disease, percutaneous stenting has been shown to be superior to endoscopic stenting. Endosonography-guided biliary drainage is emerging as an alternative technique, particularly when ERCP is not possible or fails. Metal stents are usually preferred over plastic stents, both for ERCP and for percutaneous biliary drainage. There is no consensus as to whether it is necessary to place multiple stents within advanced hilar blocks or whether unilateral stenting would suffice. However, recent data have suggested that, contrary to previous belief, it is useful to drain more than 50% of the liver volume for favorable long-term results. In the presence of cholangitis, it is beneficial to drain all of the obstructed biliary segments. Surgical bypass plays a limited role in palliation and is offered primarily as a segment III bypass if, during a laparotomy for resection, the tumor is found to be unresectable. Photodynamic therapy and, more recently, radiofrequency ablation have been used as adjuvant therapies to improve the results of biliary stenting. The exact technique to be used for palliation is guided by the extent of the biliary involvement (Bismuth class) and the availability of local expertise.
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Abstract
Biliary stenting has evolved dramatically over the past 30 years. Advancements in stent design have led to prolonged patency and improved efficacy. However, biliary stenting is still affected by occlusion, migration, anatomical difficulties, and the need for repeat procedures. Multiple novel plastic biliary stent designs have recently been introduced with the primary goals of reduced migration and improved ease of placement. Self-expandable bioabsorbable stents are currently being investigated in animal models. Although not US Food and Drug Administration approved for benign disease, fully covered self-expandable metal stents are increasingly being used in a variety of benign biliary conditions. In malignant disease, developments are being made to improve ease of placement and stent patency for both hilar and distal biliary strictures. The purpose of this review is to describe recent developments and future directions of biliary stenting.
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Affiliation(s)
- Clark D Hair
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
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8
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Katanuma A, Irisawa A, Itoi T. Otaru consensus on biliary stenting for unresectable malignant hilar biliary obstruction. Dig Endosc 2013; 25 Suppl 2:58-62. [PMID: 23617651 DOI: 10.1111/den.12067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 12/26/2012] [Indexed: 01/09/2023]
Abstract
Biliary stenting for unresectable malignant biliary strictures is widely accepted and is routinely done as an effective palliation therapy. However, a consensus among experts is still far from being reached on the selection of stents, placement procedures etc. In 2012, the European Society of Gastrointestinal Endoscopy reported guidelines for biliary stenting. At the Endoscopic Forum Japan 2012, a consensus meeting was held to examine seven statements that had been prepared based on these guidelines.Herein, we report the contents and the results of the examination of three of these statements on biliary stenting for hilar strictures.
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Affiliation(s)
- Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan.
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9
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Abstract
Endoscopic therapy is essential in the management of malignant and benign biliary strictures. With new advancements in biliary stent technology and the many controversies surrounding biliary stenting, managing biliary strictures is not always straightforward. The purpose of this article is to review the major issues surrounding biliary stenting, summarize current treatment strategies, discuss advancements in stent technologies, and describe emerging indications of biliary stents.
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10
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Abstract
Hilar cholangiocarcinoma has a poor prognosis and surgery remains the only curative option. However, few patients are diagnosed at a curable stage and palliative therapies are, therefore, mandatory. Endoscopy could have a useful role in the work-up of patients with hilar cholangiocarcinoma who are unsuitable for surgery. Endoscopic retrograde cholangiopancreatography provides an opportunity to collect specimens for cytological or histological diagnosis, yet is often nondiagnostic. Other techniques, including fluorescence in situ hybridization, confocal laser endomicroscopy and endoscopic ultrasonography, are now improving the accuracy of tissue diagnosis. This Review presents an overview of the diagnostic and therapeutic role of endoscopic procedures in the management of hilar cholangiocarcinoma. The use of such procedures in guiding the therapeutic management of patients with hilar cholangiocarcinoma is discussed, and the relative success of endoscopic stenting as the main palliative therapy for obstructive jaundice (a common complication of hilar cholangiocarcinoma) is described. The potential role of photodynamic therapy as a palliative treatment for patients with hilar cholangiocarcinoma is also outlined.
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Pisello F, Geraci G, Modica G, Sciumè C. Cholangitis prevention in endoscopic Klatskin tumor palliation: air cholangiography technique. Langenbecks Arch Surg 2009; 394:1109-14. [PMID: 19707784 DOI: 10.1007/s00423-009-0548-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Accepted: 07/30/2009] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Endoscopic biliary drainage is the treatment of choice for inoperable hilar cholangiocarcinoma (so-called Klatskin tumor). Cholangitis is the main complication post-endoscopic retrograde cholangiopancreatography (ERCP) in Klatskin patients, specially when medium contrast is injected into biliary tree that could not be subsequently drained. Bacterial cholangitis is the principal cause of mortality in these patients. The aim of this study is to analyze cholangitis rate resulting from the use of air versus iodine contrast to obtain cholangiography during ERCP. METHODS In 9 years, 188 inoperable Klatskin patients were recruited and divided into two groups: iodine (A) or air (B) contrast cholangiography, respectively. We used air or iodine contrast to obtain cholangiography before hilar stricture stenting. We retrospectively compared these data in both groups. RESULTS The group B had a significant lower rate of cholangitis than group A in Bismuth type II (p < 0.05), in Bismuth type III (p < 0.05), and in the Bismuth type IV population (p < 0.05). CONCLUSION The air contrast cholangiography is a safe and effective method, and it appears justified as a routine procedure to prevent or reduce the risk of post-ERCP cholangitis, specially in Klatskin patients (p < 0.005).
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Rerknimitr R, Kongkam P, Kullavanijaya P. Outcome of self-expandable metallic stents in low-grade versus advanced hilar obstruction. J Gastroenterol Hepatol 2008; 23:1695-701. [PMID: 18713305 DOI: 10.1111/j.1440-1746.2008.05562.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Self-expandable metallic stents (SEMS) are known to provide a longer patency time than plastic stents for malignant biliary obstructions including hilar obstruction. However, studies that focus on the efficacy of SEMS in low-grade and advanced hilar obstructions are still scanty. METHODS Ninety four patients with malignant hilar obstructions were enrolled (six were later excluded). Patients were divided into two groups according to their Bismuth levels. Group A were patients with Bismuth I (n = 53). Group B were patients with Bismuth II, III and IV (n = 35). Technical success, complications, jaundice resolution, stent patency time, and patients' survival were analyzed. RESULTS Our intention-to-treat analysis showed that group A had a significant lower rate of post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis than group B; 16.1% versus 44.7%, (P < 0.01). Four patients from group B still had persistent jaundice. Our per protocol analysis demonstrated that median stent patency time in groups A and B were not statistically different (74 vs 60 days). Median survival time in groups A and B were also not statistically different (90 vs 75 days). In both groups, those without liver metastasis had significantly better patency and survival time than those with liver metastasis (P = 0.010 and 0.027, respectively). CONCLUSIONS In patients with hilar obstruction, liver metastasis is one of the main factors that determine survival of the patient. Patency times of SEMS in both low-grade and advanced obstructions are comparable. However, in the advanced group, there is a significant risk of post-ERCP cholangitis.
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Affiliation(s)
- Rungsun Rerknimitr
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Singh V, Singh G, Verma GR, Gupta V, Gupta R, Kapoor R, Sharma N, Bhalla A. CONTRAST-FREE BALLOON-ASSISTED UNILATERAL PLASTIC STENTING IN MALIGNANT HILAR BILIARY OBSTRUCTION: A NEW METHOD. Dig Endosc 2008. [DOI: 10.1111/j.1443-1661.2008.00805.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Abstract
Biliary strictures at the liver hilum are caused by a heterogeneous group of benign and malignant conditions. In the absence of a clear-cut benign etiology, i.e. bile duct damage during surgery, hilar biliary strictures remain a diagnostic and therapeutic challenge for which a multidisciplinary approach is often necessary. A definitive diagnosis can be achieved in only 40-60% of the patients, while in all the other cases strictures are treated as though they are malignant until surgical pathology determines otherwise. Surgical resection is the only treatment that prolongs survival in patients with malignant strictures. Because these tumors frequently extend longitudinally via the hepatic ducts into the liver parenchyma, partial hepatic resection has been gradually added to biliary resection to ensure tumor-free surgical margins. For unresectable cases, endoscopic stenting of biliary obstruction is considered the preferred palliation modality to relieve pruritus, cholangitis, pain and jaundice, while the percutaneous approach has been reserved for cases of failure. Other modalities of treatment such as radiotherapy, chemotherapy, and photodynamic therapy currently remain investigational. For benign post surgical hilar strictures, surgical repair can be difficult and requires specific skills and experience. As an alternative, a multi-stent technique with endoscopic placement of an increasing number of stents over time until complete resolution of the stricture has been proposed.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Rome, Italy
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De Palma GD, Lombardi G, Rega M, Simeoli I, Masone S, Siciliano S, Maione F, Salvatori F, Balzano A, Persico G. Contrast-free endoscopic stent insertion in malignant biliary obstruction. World J Gastroenterol 2007; 13:3973-6. [PMID: 17663512 PMCID: PMC4171170 DOI: 10.3748/wjg.v13.i29.3973] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To present a case series of MRCP-guided endoscopic biliary stent placement, performed entirely without contrast injection.
METHODS: Contrast-free endoscopic biliary drainage was attempted in 20 patients with malignant obstruction, unsuitable for resection on the basis of tumor extent or medical illness. MRCP images were used to confirm the diagnosis of tumor, to exclude other biliary diseases and to demonstrate the stenoses as well as dilation of proximal liver segments. The procedure was carried out under conscious sedation. Patients were placed in the left lateral decubitus position. The endoscope was inserted, the papilla identified and cannulated by a papillotome. A guide wire was inserted and guided deeply into the biliary tree, above the stenosis, by fluoroscopy. A papillotomy approximately 1 cm. long was performed and the papillotome was exchanged with a guiding-catheter. A 10 Fr, Amsterdam-type plastic stent, 7 to 15 cm long, was finally inserted over the guide wire/guiding catheter by a pusher tube system.
RESULTS: Successful stent insertion was achieved in all patients. There were no major complications. Successful drainage, with substantial reduction in bilirubin levels, was achieved in all patients.
CONCLUSION: This new method of contrast-free endoscopic stenting in malignant biliary obstruction is a safe and effective method of palliation. However, a larger, randomized study comparing this new approach with the standard procedure is needed to confirm the findings of the present study.
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Affiliation(s)
- Giovanni D De Palma
- Department of General Surgery, Oncologic Surgery and Advanced Technologies-Center for Technical Innovation in Surgery, University of Naples Federico II, School of Medicine, Via Pansini, 5. 80131 Naples, Italy.
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Cipolletta L, Rotondano G, Marmo R, Bianco MA. Endoscopic palliation of malignant obstructive jaundice: an evidence-based review. Dig Liver Dis 2007; 39:375-88. [PMID: 17317347 DOI: 10.1016/j.dld.2006.12.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Revised: 11/14/2006] [Accepted: 12/14/2006] [Indexed: 12/11/2022]
Abstract
Endoscopic stent insertion is considered the method of choice for palliative treatment of malignant biliary obstruction. Nonetheless, relevant studies are often underpowered or outdated and do not compare actual surgical outcomes with latest stent technology. Purpose of this review was to assess, with an evidence-based methodology, the role of endoscopic versus surgical palliation of patients with malignant obstructive jaundice with special reference to clinical effectiveness, safety aspects and economic outcomes.
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Affiliation(s)
- L Cipolletta
- Department of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre del Greco, Naples, Italy
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Singh V, Kapoor R, Solanki KK, Singh G, Verma GR, Sharma SC. Endoscopic intraluminal brachytherapy and metal stent in malignant hilar biliary obstruction: a pilot study. Liver Int 2007; 27:347-52. [PMID: 17355456 DOI: 10.1111/j.1478-3231.2006.01439.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND/AIMS Malignant hilar biliary obstruction carries a poor prognosis, as the disease is often unresectable at the time of diagnosis. Various palliative measures as surgical/radiological/ endoscopic drainage with or without radiotherapy/chemotherapy have been tried with dismal outcome. We prospectively studied the effect of unilateral metal stent with intraluminal high dose rate (HDR) brachytherapy in patients with type II malignant hilar biliary obstruction. METHODS Eight patients with type II malignant hilar biliary obstruction were treated with contrast-free unilateral metal stenting followed by endoscopic intraluminal brachytherapy (ILBT). A retrospectively analyzed group of 10 patients treated only with contrast-free unilateral metal stenting served as historical controls. RESULTS A successful drainage was achieved in all, cholangitis occurred in none and no patient died within 30 days in both groups. The mean (+/-SD) patency of metal stent was 305 (+/-183.96) days and 143.9(+/-115.11) days in patients with and without intraluminal brachytherapy, respectively (P=0.03). Mean (+/-SD) survival of these patients was 310 (+/-192.68) days and 154.9 (+/-122.51) days in patients with and without intraluminal brachytherapy, respectively (P=0.05). Kaplan-Meier analysis showed estimated median survival of 225 (95% CI; 169.5, 280.4) days in brachytherapy and 100 (95%CI; 94.1, 105.8) days in control group (P=0.025). No major complications related to metal stent or ILBT were observed. CONCLUSIONS Contrast-free unilateral metal stenting with HDR ILBT in type II malignant hilar biliary obstruction is a safe and effective method of palliation and appears to prolong patient survival as well as patency of stent in these patients, however, a larger, randomized trial is required to validate the same.
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Affiliation(s)
- Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
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